Gastroenterology Today Summer 2022

Gastroenterology Today Summer 2022

Gastroenterology Today Summer 2022


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Volume 32 No. 2

Summer 2022

In this issue




Anyone for

Mobile Endoscopy?

Endoscopy sees increased activity,

but waiting lists remain challenging

The recent record surge in the number of NHS

patients being referred for cancer checks is part of a

welcome increase in diagnostics activity as the NHS

looks to refocus on waiting lists post-pandemic.

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6 FEATURE Gluten-free diet offers an effective option for

those with IBS to manage their symptoms

9 FEATURE Magnifying endoscopic findings of early-stage

poorly differentiated colorectal adenocarcinoma:

a case report

Matthew’s Perspective:

15 FEATURE Postpolypectomy fever in patients with serious

infection: a report of two cases


28 REPORT The Cost of Opioid-induced constipation (OIC)

An essential report into the financial and personal

cost of OIC


This issue edited by:

Hesam Ahmadi Nooredinvand

c/o Media Publishing Company



Upper Sapey, Worcester, WR6 6XR

What approach has 18 Week Support

taken with regards to building an

expert insourcing team?


Media Publishing Company

Greenoaks, Lockhill

Upper Sapey, Worcester, WR6 6XR

Tel: 01886 853715

E: info@mediapublishingcompany.com

Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the


best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well

above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data

is an excellent quality indicator, we now want to go a step beyond that and PUBLISHING monitor the Non-Technical DATES: skills (NTS) of each

clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our

March, June, September and December.

quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.

Tammy and Lisa’s Perspective:


Tammy Kingstree is Lead Nurse for Endoscopy.

Media Publishing Company

‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from


our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know

and to deal effectively with any issues which may arise on the day’. Lockhill

Upper Sapey, Worcester, WR6 6XR

Lisa Phillips is Lead Nurse for Endoscopy.

‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear,

team cohesion and focus are exceptionally good. It therefore shouldn’t matter PUBLISHERS that we are in an unfamiliar STATEMENT:

endoscopy unit,

the service should be seamless. If it isn’t, we do not stop until we get it right. The views and opinions expressed in

this issue are not necessarily those of

If you have an excellent NHS record and want to help clear NHS waiting list backlogs, reduce RTT waiting times and provide

the Publisher, the Editors or Media

high-quality patient care, get in touch by calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com

Publishing Company.


In this edition, Dr Matthew Banks, Clinical Lead for Gastroenterology at

18 Week Support, explores what it is like to deliver endoscopy as part of

a team in a modular endoscopy suite. These mobile units are increasingly

popular for Trusts looking to secure extra theatre capacity quickly and cost

effectively. With diagnostic waiting times still at record highs, it is likely that

many of you will at some point work in such units, and Matthew’s experience

and insights will hopefully prove helpful.

Next Issue Autumn 2022

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“A recent large


study by the



group found

that gluten free

diet has similar

efficacy to a


diet which can

perhaps provide

a simpler and

less restrictive

dietary option in

some patients

with IBS.”

Irritable bowel syndrome is a prevalent functional gastrointestinal disorder accounting

for approximately a quarter of gastroenterologists’ time in the outpatient clinic. We know

that diet plays a crucial role in management of these patients however choosing the right

diet can be challenging.

One of the most commonly used diets is the low FODMAP diet and although there is

evidence to suggest many patients with IBS benefit from this, it is quite a restrictive diet

meaning adherence can be an issue. A recent large multicenter study by the Sheffield

Gastroenterology group found that gluten free diet has similar efficacy to a low FODMAP

diet which can perhaps provide a simpler and less restrictive dietary option in some

patients with IBS. We have an article summarising these findings in this summer issue of

Gastroenterology Today. Other articles include:

• Case report highlighting the importance of careful lesion assessment through use of

magnification and chromoendoscopy to predict histology and hence appropriateness of

endoscopic resection of a lesion found during endoscopic examination

• Two cases of post-polypectomy fever, a rare but potentially serious condition with lifethreatening

complications, highlighting the importance of early recognition and prompt

antibiotic therapy

Hesam Ahmadi Nooredinvand,

St George’s Hospital



Prescribe Entocort ® CR by brand

instead of prednisolone

• Rapid induction of remission from 2 weeks with

Entocort ® CR* 1

• ~50% fewer corticosteroid-associated side effects

than prednisolone 2,3

• Unlike Entocort ® CR, prednisolone increases

susceptibility to, and severity of, infections †2,4

• Entocort ® CR is the only controlled-release

oral budesonide indicated for Crohn’s disease 2

Help keep your Crohn’s patients out of hospital...

...and where they want to be

*Remission was defined as a score of ≤150 on the Crohn’s disease activity index.

†Entocort ® CR should be used with caution in patients with infections where the use of glucocorticosteroids may have unwanted effects. 2

ENTOCORT CR 3mg Capsules (budesonide) - Prescribing


Please consult the Summary of Product Characteristics (SmPC) for full

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Presentation: Hard gelatin capsules for oral administration with an

opaque, light grey body and an opaque, pink cap marked CIR 3mg in black

radial print. Contains 3mg budesonide. Indications: Induction of remission

in patients with mild to moderate Crohn’s disease affecting the ileum and/or

the ascending colon. Induction of remission in patients with active

microscopic colitis. Maintenance of remission in patients with microscopic

colitis. Dosage and administration: Active Crohn’s disease (Adults): 9mg

once daily in the morning for up to eight weeks. Full effect achieved in 2-4

weeks. When treatment is to be discontinued, dose should normally be

reduced in final 2-4 weeks. Active microscopic colitis (Adults): 9mg once

daily in the morning. Maintenance of microscopic colitis (Adults): 6mg once

daily in the morning, or the lowest effective dose. Paediatric population: Not

recommended. Older people: No special dose adjustment recommended.

Swallow whole with water. Do not chew. Contraindications:

Hypersensitivity to the active substance or any of the excipients. Warnings

and Precautions: Side effects typical of corticosteroids may occur. Visual

disturbances may occur. If a patient presents with symptoms such as

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referral to an ophthalmologist for evaluation of the possible causes.

Systemic effects may include glaucoma and when prescribed at high doses

for prolonged periods, Cushing’s syndrome, adrenal suppression, growth

retardation, decreased bone mineral density and cataract. Caution in

patients with infection, hypertension, diabetes mellitus, osteoporosis,

peptic ulcer, glaucoma or cataracts or with a family history of diabetes or

glaucoma. Particular care in patients with existing or previous history of

severe affective disorders in them or their first degree relatives. Caution

when transferring from glucocorticoid of high systemic effect to Entocort

CR. Chicken pox and measles may have a more serious course in patients

on oral steroids. They may also suppress the HPA axis and reduce the stress

response. Reduced liver function may increase systemic exposure. When

treatment is discontinued, reduce dose over last 2-4 weeks. Concomitant

use of CYP3A inhibitors, such as ketoconazole and cobicistat-containing

products, is expected to increase the risk of systemic side effects and

should be avoided unless the benefits outweigh the risks. Excessive

grapefruit juice may increase systemic exposure and should be avoided.

Patients with fructose intolerance, glucose-galactose malabsorption or

sucrose-isomaltase insufficiency should not take Entocort CR. Monitor

height of children who use prolonged glucocorticoid therapy for risk of

growth suppression. Interactions: Concomitant colestyramine may

reduce Entocort CR uptake. Concomitant oestrogen and contraceptive

steroids may increase effects. CYP3A4 inhibitors may increase systemic

exposure. CYP3A4 inducers may reduce systemic exposure. May cause low

values in ACTH stimulation test. Fertility, pregnancy and lactation: Only

to be used during pregnancy when the potential benefits to the mother

outweigh the risks for the foetus. May be used during breast feeding.

Adverse reactions: Common: Cushingoid features, hypokalaemia,

behavioural changes such as nervousness, insomnia, mood swings and

depression, palpitations, dyspepsia, skin reactions (urticaria, exanthema),

muscle cramps, menstrual disorders. Uncommon: anxiety, tremor,

psychomotor hyperactivity. Rare: aggression, glaucoma, cataract, blurred

vision, ecchymosis. Very rare: Anaphylactic reaction, growth retardation.

Prescribers should consult the summary of product characteristics in

relation to other adverse reactions. Marketing Authorisation Numbers,

Package Quantities and basic NHS price: PL 36633/0006. Packs of 50

capsules: £37.53. Packs of 100 capsules: £75.05. Legal category: POM.

Marketing Authorisation Holder: Tillotts Pharma UK Ltd, The Stables,

Wellingore Hall, Wellingore, Lincoln, LN5 0HX. Date of preparation of PI:

February 2020

Adverse events should be reported.

Reporting forms and information can be

found at https://yellowcard.mhra.gov.uk.

Adverse events should also be reported to

Tillotts Pharma UK Ltd. Tel: 01522 813500.

References: 1. Campieri M et al. Gut 1997; 41: 209–214. 2. Entocort ®

CR 3 mg capsules – Summary of Product Characteristics. 3. Rutgeerts

P et al. N Engl J Med 1994; 331: 842–845. 4. Prednisolone 5 mg tablets

– Summary of Product Characteristics.

Date of preparation: August 2021. PU-00572.





New research from the Sheffield Gastroenterology group has

found that a gluten-free diet offers an equally effective dietary

treatment option for those with irritable bowel syndrome (IBS)

looking to manage their symptoms, alongside first and secondline

dietary advice currently recommended.

In the largest multicentre study of its kind, researchers investigated the

long-term use of the low-FODMAP diet, the recommended second-line

dietary treatment option, amongst IBS patients originally advised on the

diet by dietitians based in 5 key UK hospitals 1 . The study found that the

low FODMAP diet had longevity and continued success for the majority

of patients with 76% continuing to follow a personalised form of the diet

up to 8 years later.

A key insight from the study was that 68% of these patients who

reported to be following a personalised low FODMAP diet in the long

term, regularly purchased specialist gluten and wheat-free products to

help manage their symptoms. This led researchers to question whether

the gluten-free diet may in fact be a simpler route to the same benefit

and whether the gluten-free diet is in fact the crux of the ‘personalised’

low FODMAP diet, which has the potential to benefit a large percentage

of IBS sufferers. This ‘FODMAP light’ or ‘FODMAP gentle’ approach

could provide an alternative ‘bottom up’ management approach for IBS

alongside the existing ‘top down’ low FODMAP diet (see fig. 1).

IBS (see fig. 2). Whilst traditional advice was found to be more patient

friendly, and so should remain the first-line dietary treatment option, the

low FODMAP diet and gluten-free diet should be considered as equally

effective second-line alternatives, based on patient preference and

specialist opinion. These findings are of particular relevance, given that

an earlier piece of research from the same team demonstrated inequity

in GI dietetic service provision across England, with regional differences

in the level of provision and extent of specialist care and insufficient time

for clinic appointments 3 . Given these findings, there is an urgent need to

consider less complex dietary interventions for common conditions such

as IBS in order to maximise efficiency and standards in patient care.

Dr Imran Aziz, Consultant

Gastroenterologist at the Royal

Hallamshire Hospital, Sheffield


“Diet appears to play a pivotal

role in symptom generation in IBS

patients. Over the last decade

there has been a substantial

increase in interest in the role of

dietary therapies in IBS, including

a gluten-free diet. This latest

research shows that a glutenfree

has a similar level of efficacy

Fig. 2

to traditional dietary and low

FODMAP dietary advice and so deserves a seat at the table. It is an

important step in providing IBS patients with choice, helping them to find

relief from their symptoms in the simplest, most effective way for them.”


Fig. 1

A follow-up randomised trial, led by the Sheffield team involved a headto-head

investigation looking at the best treatment options for patients

with IBS in real world conditions 2 . It compared traditional (first-line)

dietary advice, a low FODMAP diet and a gluten-free diet.

The key finding from the study was that all three diets were equally

effective in managing symptoms for patients with non-constipated

Katie Kennedy, Company Dietitian for gluten-free food manufacturer Dr

Schär who helped to fund this research, added:

“Dr Schär were delighted to support Sheffield to conduct this research, the

first study of it’s kind to compare all three major dietary interventions for

IBS. The results will empower dietitians to suggest the most appropriate

dietary treatment options for their IBS patients in a joint decision-making

process. This study proves that, if advised on and followed correctly,

traditional dietary advice can help the majority of IBS sufferers to find relief

from their symptoms, without the need for more complex and costly dietary

interventions. If traditional dietary advice fails, then there are further, equally

effective options available to patients, including a gluten-free diet”.

Further research is underway to build on these findings and provide

further impetus for a medical consensus and future change in national

guidance on IBS.



1. Rej, A, Shaw C, Buckle R et al. The low FODMAP diet for IBS: A multicentre UK study assessing long-term followup.

Dig Liver Dis 2021 Nov;53(11):1404-1411. Doi: 10.1016/j.dld.2021.05.004.Epub 2021 Jun 1

2. Rej A, Sanders DS, Shaw CC, et al. Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable

Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet and the Gluten-Free

Diet. Clin Gastroenterol Hepatol. 2022 Feb 28: S1542-3565 (22) 00202-6. doi: 10.1016/j.cgh.2022.02.045.

Online ahead of print

3. Rej A, Buckle RL, Shaw CC, et al. National survey evaluating the provision of gastroenterology dietetic services in

England. Frontline Gastroenterology 2020:flgastro-2020-101493.


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strong governance for the management of

these patients.

Endoscopy sees increased activity, but waiting lists remain challenging

The recent record surge in the number of NHS patients being referred

for cancer checks is part of a welcome increase in diagnostics activity as

the NHS looks to refocus on waiting lists post-pandemic. Other areas of

diagnostics have also seen an uptick. In colonoscopy and gastroscopy,

the latest available statistics (February 2022) show that waiting lists have

fallen by 0.9% and 11.9% respectively compared to February 2021.

However, the overall diagnostics picture remains challenging with more

than 1.5 million patients still waiting longer than the 6-week wait for the full

range of key diagnostic tests. Despite more tests being undertaken across

gastroenterology, some 63,599 patients are still waiting for colonoscopy

and 64,700 are still waiting for gastroscopy. Recent analysis by Macmillan

suggests there have been nearly 50,000 fewer cancer diagnoses due to

Covid-related delays, and the NHS will have to work at 110% capacity to

clear the backlog, taking an estimated 18 months to catch up on missed

cancer diagnoses and 15 months for cancer treatment.

Criteria & Quality

We select Endoscopists with an endoscopy

orientated career path and performance

measures above the national average. JAG

audit data is constantly monitored to ensure

ongoing quality. Furthermore, we have a

clinical governance department that is crucial

to maintaining quality and safety but also

provides support to both Endoscopists and

the units within which we work.

Trusts shift to on-site mobile and modular theatre suites to better

focus on waiting list reduction

The NHS is of course already engaged in this challenge and is rolling out

a broader mix of diagnostic services and facilities, including one-stop

shops for tests as well as symptom hotlines.

A particularly successful initiative however has been Trusts’ embracing

of mobile and modular theatre units, usually located on-site, which have

helped them focus on reducing waiting lists while keeping procedures

separated from main hospital buildings, especially important given the

need for safe Covid and general infection control.

We provide tailored solutions to manage

capacity from straight forward supply of staff

to a team based managed solution to a full

patient pathway including pathology review.

Here at 18 Week Support, the UK’s largest clinical insourcing provider,

we have provided specialist endoscopy teams for a number of Trusts

where we staff and operate mobile theatre units they have contracted

from specialist providers such as Vanguard Healthcare Solutions.

We have assisted over 55 Trusts around the country, carrying out the full

range of endoscopy procedures either in-house or in mobile theatres,

both during and after Covid-19. Indeed Trusts have been so pleased

with the mobile and modular theatre suites concept that many are now

including them in their planning for reducing waiting lists, adding new

theatre capacity quickly and cost-efficiently.

Our commitment to improving the

NHS experience

Like the NHS Trusts we work with, patient

care is at the centre of everything we do. By

using any spare weekend capacity within a

Trust, the 18 Week Support insourcing teams

are able to see a high volume of patients

in a short space of time, in the familiar

surrounding of the NHS Trust.

The experience of endoscopy delivery in modular mobile suites

But what is the actual experience like for endoscopists to work in a

stand-alone ‘cold site’?

Dr Matthew Banks, Clinical Lead for 18 Week Support Gastroenterology,

believes that although the experience is obviously new and has some

specific challenges, adaptation to the new working environment can

be rapid and relatively straightforward given 18 Week Support’s teams

are mainly drawn from existing or recently retired NHS Consultants and

nurses looking for extra shifts or to work part-time for a period.

“Endoscoping in a mobile or semi-permanent endoscopy suite requires

a degree of flexibility and adaptability. One needs to take time getting

familiar with the unit, layout, equipment and IT. Once you have your

An ethical company

We’re Matthew. an ethical and transparent company

that’s financially accountable and financially

responsible. We’re committed to the NHS

8 and the delivery of high-quality care, and to

helping Trusts reduce RTT waiting times.

awareness, it is very much like scoping in any endoscopy unit”, said

Staff do however need to be aware of the limitations. Matthew added,

“Often you are isolated, with no, or very limited clinical back up and

this dictates the level of complexity of the patients being endoscoped.

Complex therapeutics and high-risk patients (ASA grade III/IV) are

usually avoided, and the bulk of the work is straightforward diagnostic


Those working in insourcing teams like 18 Week Support will often find

themselves working with different nurses through the course of a week,

or over a longer period of time. Leadership, patience and understanding

is needed to ensure the quality delivered is constant and of a high level.

In addition, each unit team will typically have a Nurse in Charge (NIC)

who runs the day and the lists. For consultants, focussing on their

role as the endoscopist is key, and working as a team is essential in

Happy patient

ensuring all patients are managed appropriately. “Whilst in the room,

the endoscopist needs to show leadership, but they also need to

understand that someone else is actually in charge of the unit, and this

can be a challenge for many consultant endoscopists”, said Matthew.

Who we’re looking for

Another “working-life” difference arises not from working in a mobile unit

per We se, are but interested from working for in a third-party meeting organisation with Consultant

within NHS

Trust framework. This relationship necessarily means that patients are

Gastroenterologists, senior nurses and clinical

not followed up by the endoscopist, histology is often not available to

review nurse after specialists the event and sometimes throughout clinical the information UK. can be quite

limited. Moreover, because of the COVID pandemic, the endoscopist

is often the first ‘face to face’ consultation the patient has had in two

years. The pre-procedure process is therefore key to understanding the

Our remuneration package is second to

patients concerns and ensuring the correct procedure is completed -

or occasionally no procedure performed at all.

none and is per session rather than per case

which allows our teams to work in a safe and

The quality and performance of the 18 Week Support teams is not

only reflected in its JAG data but also across its patient satisfaction

scores calm which environment’

are exemplary across the UK. Recruiting high-performing

endoscopists that are passionate about their work helps ensure

18 Week Support’s JAG safety and quality data is above the national

average as documented in the national endoscopy database.

About you

Clinical team


For those looking for additional career experience and exposure from

working in an insourcing endoscopy team, Matthew advises that


If you


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18 Week Support


Dr Matthew Matthew Banks Banks

Clinical Lead for Gastroenterology

18 Week Support

London 3rd Floor, 19-21 Great Tower Street, London EC3R 5AR

Birmingham Unit 25, Lichfield Business Village, The Friary WS13 6QG

Follow us: 18-week-support 18 Week Support @18WeekSupport






Haiyan Li 1 , Yao Liu 2 and Jianhong Zhu 1*

Li et al. BMC Gastroenterology (2022) 22:148 https://doi.org/10.1186/s12876-022-02209-w


Case presentation

Background: Colorectal poorly differentiated adenocarcinoma is

rarely founded, especially in early-stage. Endoscopic features of early

poorly differentiated colorectal cancer in magnifying endoscopy and

chromoendoscopy haven’t been clarified.

Case presentation: A 49-year-old man was referred to our hospital

for endoscopic treatment of a lateral spread tumor located in the

rectum. We performed pre-resection endoscopic examination for the

patient. In magnifying endoscopy with crystal violet staining, the lesion

showed irregular microvessels and turned out to be poorly stained

with predominantly non-structural pit pattern and a few roundish pits

scattered on the surface. The histology revealed a poorly differentiated

adenocarcinoma of the rectum invading the deep submucosal layer with

negative lymphovascular invasion.

Conclusions: In this case report, we presented a case of poorly

differentiated colorectal adenocarcinoma detected at an early stage,

showing interesting endoscopic findings in magnifying endoscopy with

crystal violet staining.

Keywords: Colorectal poorly differentiated adenocarcinoma, Magnifying

endoscopy, Chromoendoscopy, De-novo colorectal cancer, Case report


Colorectal poorly differentiated adenocarcinoma is rarely

founded, especially in early-stage. Most cases are detected at an

advanced stage. In contrast to differentiated adenocarcinoma,

poorly differentiated adenocarcinoma often correlates with more

aggressive biological behavior and is defined to be out-ofindication

for endoscopic resection even in early-stage. Thus, the

endoscopic diagnosis of poorly differentiated adenocarcinoma is

important. Several endoscopic diagnostic classifications, including

Kudo’s pit pattern classification, have been proposed and proved

to distinguish colorectal cancer from non-neoplastic lesion or

adenomas, as well as predict the depth of invasion in colorectal

cancer. These diagnostic methods mostly focus on adenomas

or differentiated adenocarcinomas. Perhaps due to its rarity,

endoscopic features of early poorly differentiated colorectal cancer

in magnifying endoscopy and chromoendoscopy haven’t been

clarified. We here present a case of poorly differentiated colorectal

cancer in the early-stage, showing specific findings in magnifying

endoscopy with crystal violet staining.

A 49-year-old man was referred to our hospital for endoscopic

therapy of a lateral spread tumor (LST) in the rectum in December

2019. At the previous hospital, biopsy histology showed high-grade

intraepithelial neoplasia (HGIN). He had a three-week history of

intermittent hematochezia. Family history for colorectal malignancy was

negative. Physical examinations and routine laboratory tests revealed

no abnormalities. Before resection, the patient underwent a magnifying

chromoendoscopy examination. White-light endoscopy showed a

superficially elevated lesion with slight depression in the central part,

together with a reddish scar due to previous biopsy (Fig. 1A). The

proximal part of the lesion presented with dense irregular microvessels

in NBI mode (Fig. 1B). In magnifying endoscopy combined with 0.05%

crystal violet staining, the proximal part showed irregular microvessels

and turned out to be poorly stained with predominantly non-structural

pit pattern, while the background mucosa showed regular Type-I pit

patterns according to the Kudo’s classification (Fig. 1C). The distal part

showed poorly stained with predominantly non-structural pit pattern,

as well as a few small roundish pits scattered over the surface (Fig.

1D). The demarcation line between the lesion and normal mucosa was

clearly visible. The whole lesion was lifted after submucosal injection

and then resected completely (Fig. 2A) through endoscopic submucosal

dissection (ESD). Histology of the resected sample showed poorly

differentiated adenocarcinoma invading into deep submucosal layer, with

negative lymphovascular invasion and negative resection margin (Fig.

2B–D). P53 Immunohistochemistry staining showed complete absence

in the cancerous area, which was predictive of TP53 truncated mutation.

The MMR and APC genes showed intact expression, and ß-catenin was

expressed in the cellular membrane and cytoplasm (Fig. 3). KRAS gene

mutation was conducted through Polymerase Chain Reaction (PCR)

and also showed negative results. The patient then underwent additional

surgery with lymph node dissection and final histology showed no

residual tumor and no lymph node involvement. Follow-up surveillance

colonoscopy and contrast enhanced computed tomography were

performed for the patient in both the first year and second year after

surgery. Neither local recurrence nor distant metastasis was detected

over a two-year follow-up period.

Discussion and conclusions

Endoscopic resection is indicated for Tis or T1 tumors and

pathological findings of unfavorable features including poorly

differentiation and deep submucosal infiltration are considered to be

non-curative [1]. Magnifying endoscopy with chemical dye staining

is usually conducted for pre-resection assessment in these cases.


*Correspondence: zhujianhong1980@sina.com


Department of Gastroentorology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China


Department of Pathology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.

©The Author(s) 2022



Kudo’s pit pattern classification, which shows the relationship

between pit patterns and histology, is accurate in differentiating

neoplastic and non-neoplastic lesions and predicting tumor invasion

depth. However, there has been no endoscopic diagnosing criteria

in determining histologic type and tumor degree of differentiation

for colorectal cancers. Reviewing the literature, we found a few

case reports clarifying the endoscopic features of early-stage

signet ring cell carcinoma in the colorectum [2,3,4]. To the best of

our knowledge, there have been no reports on the magnifying nor

the chromoendoscopic findings of poorly differentiated colorectal


Ohnita et al. [2] reported a primary signet ring cell carcinoma

detected at an early stage. As they reported, the margin of the

lesion showed IIIL and V I

pit patterns, while the central part of the

lesion showed V I

pit pattern and dense mucus. Similar findings

have been reported by Fu et al. [3]. As they explained, signet ring

cells preferred to produce mucus so such lesions were difficult

to stain and showed avascular areas. However, there was no

obvious mucus in our case and the whole lesion was also difficult

to stain using either indigo carmine or crystal violet. In our case,

the histology revealed a large number of tumor cells overgrowing

and loss of normal surface epithelium and crypt-like structure

in the mucosal layer. These findings may explain why the lesion

was poorly stained. In some histologic sections we observed a

few normal glandular ducts surrounded by tumors cells (Fig. 2D),

which was consistent with the scattered roundish pits, i.e., Type-I

pit patterns in magnifying endoscopy. Minamide et al. [4] reported

similar findings in colorectal signet ring cell carcinoma but the lesion

was residual after cold snare polypectomy and the diagnosing

information may be not adequate. In Kudo’s classification, Type V N

pit-pattern refers to loss or decrease of pits with an amorphous

structure and indicates invasive submucosal colorectal cancer.

Usually, Type V N

pit-pattern co-exists with Vi pit-pattern or scratch

sign. The lesion in our case presented poorly stained feature with

predominately non-structural pit pattern and a few roundish pits

scattered on the surface. No obvious Vi pit-pattern or scratch sign

was found. These features were different from those of typical Type


pit-pattern in Kudo’s classification. We confused at the failing

to stain the lesion in the beginning and we repeated several times

and the outcomes turned out to be the same. Besides the poorly

stained feature, the proximal part of the lesion showed irregular

microvessels similar to corkscrew vessels which indicated poorly

differentiated cancer in the stomach.


Fig. 1 A White light endoscopy revealed a lateral spread tumor in the rectum. B In near focus NBI mode, the proximal part of the lesion presented

with dense irregular microvessels. C In magnifying endoscopy combined with 0.05% crystal violet staining, the proximal part of the lesion showed

poorly stained with predominantly non-structural pit pattern, while the background mucosa showed regular Type-I pit patterns according to the

Kudo’s classification. The demarcation line was clearly visible (white dotted line). D In magnifying endoscopy combined with 0.05% crystal violet

staining, the distal part showed poorly stained with predominantly non-structural pit pattern and a few roundish pits (black arrow) scattered over

the surface



Fig. 2 A The lesion was en bloc resected. B The specimen was sectioned at 2 mm intervals. C Histology showed poorly differentiated colorectal

cancer with partial submucosal infiltration (black arrow). Stain: hematoxylin and eosin. D In some sections, histology showed a few normal glandular

ducts (black arrow) surrounded by tumors cells, which is corresponding to the endoscopic feature, i.e., small roundish pits scattered over the surface

This was the first time we encountered with early poorly

differentiated colorectal cancer and due to the lack of adequate

knowledge, we initially performed endoscopic submucosal

dissection for the patient. Non-curative endoscopic treatment

resulted in increases in time and cost and decreased patient’s

satisfaction. From our case, we suppose that poorly stained

features with predominantly non-structural pit pattern in magnifying

endoscopy with crystal violet staining may be related to poorly

differentiation and thus be inappropriate for endoscopic resection.

More researches are needed to make a definite conclusion.





Fig. 3 Immunohistochemistry staining of the lesion

At the same time, we also analyzed the molecular features of the

lesion. Colorectal cancers are heterogenous at the genetic level and

develop via accumulation of genetic molecular alterations, in which

APC, KRAS, TP53 mutations are mostly founded. Several pathways

have been proposed for the development and progression of colorectal

cancer, including the widely accepted adenoma-carcinoma sequence,

the serrated neoplasia pathway, and de-novo carcinogenesis [5].

By definition, de-novo lesions are characterized by the lack of any

adenomatous remnant. In our case, the lesion presented with

nonpolypoid growth pattern and no adenomatous remnant was founded.



Immunohistochemical and molecular analysis of the lesion implied p53

mutation, without any of APC, ß-catenin, or KRAS mutation. Thus, we

suppose that the cancerous lesion in our case is associated with p53

mutation, in accordance with molecular changes of de-novo colorectal


of Pathology, The Second Affiliated Hospital of Soochow University,

Suzhou, Jiangsu Province, China.

Received: 6 August 2021 Accepted: 12 March 2022

Published online: 28 March 2022

Availability of data and materials

All data generated or analysed during this study are included in this

published article.


LST: Lateral spread tumor; HGIN: High-grade intraepithelial neoplasia;

NBI: Narrow band imaging; ESD: Endoscopic submucosal dissection;

P53: Protein 53; TP53: Tumor protein 53; MMR: Mismatch repair

proteins; MSH2: MutS homolog 2; MSH6: MutS homolog 6; MLH1:

MutL homolog 1; PMS2: Postmeiotic segregation increased 2; APC:

Adenomatous polyposis coli; KRAS: Kirsten rat sarcoma viral oncogene

homolog; PCR: Polymerase chain reaction.


Not applicable.

Authors’ contributions

HL conducted this report and prepared the manuscript. JZ performed

the colonoscopy and provided the endoscopic images. YL performed

the histological examination and provided the histology images. All

authors read and approved the final manuscript.


1. Shinagawa T, Tanaka T, Nozawa H, et al. Comparison of the

guidelines for colorectal cancer in Japan, the USA and Europe. Ann

Gastroenterol Surg. 2017;2(1):6–12.

2. Ohnita K, Isomoto H, Akashi T, et al. Early stage signet ring cell

carcinoma of the colon examined by magnifying endoscopy with

narrow-band imaging: a case report. BMC Gastroenterol. 2015;15:86.

3. Fu KI, Sano Y, Kato S, et al. Primary signet-ring cell carcinoma of the

colon at early stage: a case report and a review of the literature. World

J Gastroenterol. 2006;12:3446–9.

4. Minamide T, Shinmura K, Ikematsu H, et al. Early-stage primary signet

ring cell carcinoma of the colon with magnifying endoscopic findings.

Gastrointest Endosc. 2019;90:529–31.

5. Papagiorgis PC, Zizi AE, Tseleni S, et al. Clinicopathological differences

of colorectal cancers according to tumor origin: identification of possibly

de novo lesions. Biomed Rep. 2013;1:97–104.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in

published maps and institutional affiliations.

ScheBo_GastroToday 29/04/2022


This work was supported by the Doctoral Program Foundation of

the Second Affiliated Hospital of Soochow University (Grant No.

SDFEYJBS2102), the Scientific Research Foundation of the Second

Affiliated Hospital of Soochow University (Grant No. SDFEYQN1811),

and the discipline construction and support project of the Second

Affiliated Hospital of Soochow University (Grant No. XKTJ-JD202006).

Funding enabled immunohistochemical and genetic analysis of the

resected sample. The funder did not influence the collection and analysis

of data, the decision to publish and the writing of the manuscript.

Availability of data and materials

All data generated or analysed during this study are included in this

published article.


Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication

of this case report and any accompanying images.

Competing interests

The authors declare that they have no competing interests.

Author details


Department of Gastroentorology, The Second Affiliated Hospital of


Soochow University, Suzhou, Jiangsu Province, China. 2 Department


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Wang Jing 1† , Li Qinghua 1† and Yang Zhiwen 2*

Jing et al. BMC Gastroenterology (2022) 22:156 https://doi.org/10.1186/s12876-022-02218-9



Postpolypectomy fever (PPF) is a rare complication in patients after

colonoscopy. Because of the absence of evidence of microperforation

and abdominal tenderness, patients with PPF usually present mild

clinical symptoms with a good prognosis.

Case presentation

In this study, all patients who underwent colonoscopic examination in our

hospital between January 2019 and December 2019 were enrolled. Of

these, two patients developed PPF after polypectomy, exhibiting serious

infection without definitive fever foci. One patient experienced rapidly

aggravated type 1 respiratory failure and abnormal hepatic function, which

were attributed to colonoscopy-associated infection. After active antibiotic

therapy, both patients were discharged without any complications.


In summary, our study provides novel insights into patients with PPF

who develop serious infections with life-threatening complications.


Postpolypectomy fever, Serious infection, Diagnose, Therapy, Patient


overlooked in clinical practice, owing to the absence of typical peritoneal

irritation and definitive fever foci. Thus, our report should aid in timely

diagnosis and appropriate therapy for patients with PPF.

Case presentation

Case selection, procedures, and definitions

In 2019, 12,000 patients underwent colonoscopic examination in our

hospital, and approximately 2000 patients with gastrointestinal polyps

received painless endoscopic treatment. These cases of colonoscopies

were performed in the outpatient and inpatient setting. All colonoscopies

were elective, not urgent. Patients who received polypectomy were

admitted to the hospital for about 2–3 days. Two patients after

colonoscopy met the inclusion criteria with a high fever up to 39.0 °C in

1–2 h, and the leukocytes, C-reactive protein (CRP) and procalcitonin

(PCT) increased significantly with signs of infection [5,6,7]. They were a

health state at admission, without any signs of fever, abdominal pain,

cough, frequent urination, infection or other discomfort. The results

of routine analyses of the blood, urine and feces were normal, and no

signs of infection were observed on chest ` abdominal CT. The patients

developed serious infections after polypectomy during hospitalization.

Physical and radiographic examination did not show evidence of

perforation, hemorrhage, abdominal tenderness or localized peritoneal

inflammation. No evidence of other explainable fever foci other than

colonoscopic polypectomy was identified.

Colonoscopy is widely used in clinical practice, although serious

complications may result from colonoscopic polypectomy [1, 2]. These

serious complications are inherent to the procedure and occur at low

incidence during colonoscopy. Hemorrhage and perforation, the most

feared complications, occur in ≤ 0.3% and 0.3–0.6% [3, 4], respectively.

Postpolypectomy electrocoagulation syndrome (PPCS), a rare

complication, ranges from 0.07 to 1.0% [3, 4].

Here, we report the cases of two patients who developed PPF after

colonoscopy, and experienced new-onset fever without localized

peritoneal signs or definitive fever foci. Aggravated serious infectious

symptoms were present with a high fever up to 39.0 °C in 1–2 h after

operation, and the patients received further therapy in the general

intensive care unit (GICU). As reported previously, patients with PPF

generally present mild clinical symptoms with good prognosis. To our

knowledge, this is the first report of patients with PPF developing serious

infections with life-threatening complications. Additionally, PPF is easily

Patients with postpolypectomy bleeding, microperforation, abdominal

tenderness, localized peritoneal inflammation and infection associated

with definitive fever foci other than colonoscopic polypectomy were


All colonoscopic polypectomies were performed with standard

colonoscopes (CF-H260AL; Olympus Optical Co., Ltd., Tokyo, Japan).

Patients were slowly intravenously injected with propofol. Patients who

received polypectomy operation were admitted to the hospital for about

2–3 days.

Patient 1

The first case was in a 50-year-old man without a notable past history,

who was diagnosed with multiple colorectal polyps. Four polyps were

found: three flat polyps with a diameter of 2–5 mm in the sigmoid colon


*Correspondence: yangzhiwen2009@sina.com † Wang Jing and Li Qinghua have contributed equally to this work


Department of Gastroenterology, Songjiang District Central Hospital, Shanghai, China 2 Department of Pharmacy, Songjiang District Central Hospital, Shanghai 201600, China

©The Author(s) 2022



(Fig. 1A, B) and a flat polyp with a diameter of 4 mm in the rectum

(Fig. 1C). He underwent colonoscopy with cold biopsy of a 4 mm rectal

polyp (Fig. 1D), and the colorectal polyps were confirmed pathologically.

Two hours after the operation, the patient developed a high fever

up to 39.4 °C. Laboratory examinations revealed elevated infection

indices, such as PCT 44.52 ng/mL, CRP 40.48 mg/L, white blood

cell count (WBC) 17.3 × 10 9 /L and neutrophils 95.4%. The result of

CT scan showed pleural effusion in lung (Fig. 2 A and B). No evidence

of other explainable fever foci was found, and no microorganisms

were found in blood cultures. Because of the serious colonoscopyassociated

infection, the patient was transferred to the GICU and

treated with antibiotic combined therapy consisting of meropenem

(1.0 g administered intravenously every 12 h) and metronidazole (0.5 g

administered intravenously every 12 h). His fever subsided within 1 day,

thus indicating that the antibiotic therapy was effective. Eventually, the

patient was discharged without any complications.

Fig. 1 Colonoscopic examination of a 50-year-old man. A A flat

polyp with a diameter of 3 mm in the sigmoid colon. B Two flat

polyps with diameters of 3–5 mm in the sigmoid colon. C A flat polyp

with a diameter of 4 mm in the rectum; D Rectal biopsy

Patient 2

The second case was in a 72-year-old woman with a history of

hypertension and fatty liver, who underwent a colonoscopy that revealed

13 polyps: four flat polyps with a diameter of 2–3 mm in the ileocecal part

(Fig. 3A), a 4 mm papillary polyp in the liver flexure of the colon (Fig. 3B),

a 3 mm flat polyp in the transverse colon (Fig. 3C) and seven flat polyps


Fig. 2 chest and abdominal CT before and after colonoscopy. A Chest CT of a 50-year-old man. Normal CT before colonoscopy, but abnormal CT

with pleural effusion after colonoscopy. B Abdominal CT of a 50-year-old man. Normal CT before and after colonoscopy. C Chest CT of a 72-year-old

woman. Normal CT before colonoscopy, but abnormal CT with pleural effusion after colonoscopy. D Abdominal CT of a 72-year-old woman.

Normal CT before colonoscopy, but abnormal CT with exudation in pancreas tail after colonoscopy



with diameters of 2–5 mm in the sigmoid colon (Fig. 3D). The colorectal

polyps confirmed pathologically were resected by argon plasma

coagulation (APC) under the condition of strong electrocoagulation

2, 40 W APC power, and 0.8–1.2 L/min argon gas flow (APC ® 2 and

electric generator vio ® 200D; ERBE Company, Tuebingen, German). One

hour after the operation, the patient suddenly developed a high fever

of 39.0°C, without cough, expectoration or abdominal pain. On the

morning of the second day, the patient’s body temperature continued

to rise to 40.0°C, Physical examination findings for the abdomen were

negative, without evidence of intestinal perforation and hemorrhage.

There was no abnormalities in routine urine examination, and no

bacterial growth in blood culture examination. Laboratory examinations

revealed 18.48 × 10 9 /L WBC, 96.1% neutrophils, more than 100.0 ng/

mL procalcitonin, 68.24 mg/L CRP. The result of CT scan showed

pleural effusion in lung and exudation in pancreas tail (Fig. 2 C and D).

Of note, the patient’s illness rapidly worsened, and she was transferred

to the GICU, with poor gas analysis (PH7.384, PCO2 34.8 mmHg, PO2

42.1 mmHg) and abnormal hepatic function results (ALT 145.9U/L, AST

256.5U/L, r-GT 215U/L). After consultation with doctors, the patient’s

symptoms, including type 1 respiratory failure and abnormal hepatic

functions, were attributed to a colonoscopy-associated infection with

subsequent gut bacterial translocation. The patient received intravenous

therapy consisting of 1.0 g of vancomycin every 12 h for 3 days, and

1.0 g of imipenem/cilastatin every 8 h for 5 days. After 2 days of therapy,

her body temperature normalized. The patient’s gas analysis (PH7.439,


33.9 mmHg, PO 2

93.3 mmHg) and liver function (ALT 27.74U/L,

AST 20.99U/L, r-GT 67.79U/L) also recovered normally. Eventually, she

was discharged without any complications.

Discussion and conclusions

In previously published reports, PPF has been considered a rare

complication of colonoscopic polypectomy with slight clinical

symptoms and good prognosis [5, 8]. To our knowledge, this study

is the first report of patients with PPF presenting serious infectious

symptoms leading to life-threatening complication, and rapid

deterioration to type 1 respiratory failure and abnormal hepatic

function. After antibiotic therapy, the patient condition rapidly


Fig. 3 Colonoscopic examination of a 72-year-old woman. A Four

flat polyps with diameters of 2–3 mm in the ileocecal part. B A 4 mm

papillary polyp in the liver flexure of the colon. C A 3 mm flat polyp in

the transverse colon. D Seven flat polyps with diameters of 2–5 mm

in the sigmoid colon

Seven patients were previously reported to develop PPF after

colonoscopic polypectomy, of which four cases had a polyp

diameter ≥ 2 cm, one case had a polyp 10–30 mm in diameter, and

two cases had no polyps [5]. The median initial time of fever after

polypectomy was approximately 7 h, and the median fever duration

was approximately 9 h [5]. The seven patients with PPF had slight

clinical symptoms with a good prognosis after antibiotic therapy [5].

CRP, a critical infection index, did not increase within 24 h [5]. In

contrast to these cases, three exceptional findings in our study were

observed. First, severe infection in patients with PPF was found,

thus resulting in type 1 respiratory failure and abnormal hepatic

function. Second, the patients with PPF had relatively smaller polyps

of 2–5 mm in diameter. Third, CRP and PCT were significantly

elevated within several hours.

Lee et al. further discussed three possible mechanisms of PPF

[5, 8]. The first is that PPF may be a mild form of PPCS that

develops by transmural burn. With the exception of abdominal

tenderness, PPF is similar in terms other clinical symptoms and

risk factors to PPCS. Notably, transmural burn in the colon wall

is significant in both PPF and PPCS, thus suggesting that both

might be generated by the same mechanism. PPF and PPCS are

initiated by different degrees of transmural burn, with or without

actual intestinal perforation. The second is that gut bacteria may

translocate to the bloodstream via mucosal wounds during the

colonoscopic procedure. The incidence of transient bacteremia was

approximately 4% within 10 min after polypectomy. Contamination

by enteric bacteria is inevitable, even when a disinfected colonoscope,

sterile needles and sterile injection fluid are used during colonoscopy [9-

11]. For instance, the propofol formulation for intravenous administration

may be a possible contamination factor [12]. The third is that PPF may

be attributable to an inflammatory mechanism other than infection.





In general, polyps induce an inflammatory microenvironment

with inflammatory cell infiltration and elevated proinflammatory

cytokines, such as IL-6 and TNF-α. Thus, determining whether the

patients with PPF developed fever because of the colonoscopy or the

polypectomy itself is difficult.

As previously reported, seven patients developed PPF, of which two

cases had no polyps, and one case had polyps 10–30 mm in diameter

[5]. This finding suggests that colonoscopic examination without

colonoscopic polypectomy also affects the intestinal bacteria or causes

minimal intestinal-barrier damage. The patients with PPF in our study

had multiple relatively small polyps (2–5 mm in diameter), in contrast

to the previously reported findings. Although the causes of PPF are

complicated, we believe that gut bacteria are translocated to the

bloodstream via mucosal wounds.

PPCS, a rare and serious complication of colonoscopic polypectomy,

results from an electrocoagulation injury to the bowel wall during

polypectomy, which induces a transmural burn and localized peritoneal

inflammation without clinical evidence of perforation on radiographic

examination [13]. Within hours to 5 days after colonoscopic

polypectomy, patients develop fever and other symptoms, including

leukocytosis, localized abdominal pain and localized peritoneal signs.

In summary, this study may increase clinical awareness regarding PPF

after colonoscopy. Early recognition and antibiotic therapy are critical,

which can improve patient prognosis and avoid severe outcomes.


PPF: Postpolypectomy fever; PPCS: Postpolypectomy

electrocoagulation syndrome; GICU: General intensive care unit; CRP:

C-reactive protein; PCT: Procalcitonin; WBC: White blood cell count;

APC: Argon plasma coagulation.


This study was supported by all physicians in the Department of

Gastroenterology, Songjiang District Central Hospital, Shanghai, China.

We thank International Science Editing for editing this manuscript.

Authors’ contributions

JW and QL designed the study. ZY analyzed data and wrote the

manuscript. All authors have read and approved the final manuscript.


This case report was supported by Shanghai Municipal Health

Bureau (201940471) and Shanghai Songjiang Science & Technology

Commission (2017sjkjgg50), which supported data collection, analysis

and manuscript writing.

Availability of data and materials

All information about the patient come from department of

Gastroenterology, Songjiang District Central Hospital. The data used and

analyzed during the current study are included in this article.


Ethics approval and consent to participate

Not applicable.

Consent for publication

The two patients gave written consent for their personal or clinical

details along with any identifying images to be published in this study.

Competing interests

The authors declare no conflicts of interest.

Author details


Department of Gastroenterology, Songjiang District Central Hospital,

Shanghai, China. 2 Department of Pharmacy, Songjiang District Central

Hospital, Shanghai 201600, China.

Received: 8 October 2021 Accepted: 16 March 2022

Published online: 29 March 2022


1. Barua I, Vinsard DG, Jodal HC, Løberg M, Kalager M, Holme Ø, et

al. Performance of artificial intelligence in colonoscopy for adenoma

and polyp detection: a systematic review and meta-analysis.

Gastrointest Endosc. 2021;93(1):277–85.

2. Benazzato L, Zorzi M, Antonelli G, Guzzinati S, Hassan C, Fantin

A, et al. Colonoscopy-related adverse events and mortality in an

Italian organized colorectal cancer screening program. Endoscopy.


3. Watabe H, Yamaji Y, Okamoto M, Kondo S, Ohta M, Ikenoue T, et

al. Risk assessment for delayed hemorrhagic complication of colonic

polypectomy: polyp-related factors and patient-related factors.

Gastrointest Endosc. 2006;64(1):73–8.

4. Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos

G, et al. Risk of perforation from a colonoscopy in adults: a large

population-based study. Gastrointest Endosc. 2009;69(3 Pt


5. Lee SH, Kim KJ, Yang DH, Jeong KW, Ye BD, Byeon JS, et al.

Postpolypectomy fever, a rare adverse event of polypectomy:

nested case-control study. Clin Endosc. 2014;47(3):236–41.

6. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report

of complications. J Clin Gastroenterol. 1992;15(4):347–51.

7. Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy

and flexible sigmoidoscopy. Gastrointest Endosc Clin N Am.


8. Kim HW. What is different between postpolypectomy fever

and postpolypectomy coagulation syndrome? Clin Endosc.


9. Levy MJ, Norton ID, Clain JE, Enders FB, Gleeson F, Limburg PJ,

et al. Prospective study of bacteremia and complications with EUS

FNA of rectal and perirectal lesions. Clin Gastroenterol Hepatol.


10. Low DE, Shoenut JP, Kennedy JK, Sharma GP, Harding GK, Den

Boer B, et al. Prospective assessment of risk of bacteremia with

colonoscopy and polypectomy. Dig Dis Sci. 1987;32(11):1239–43.

11. Nelson DB. Infectious disease complications of GI endoscopy: part

II, exogenous infections. Gastrointest Endosc. 2003;57(6):695–711.

12. Rex DK, Deenadayalu V, Eid E. Gastroenterologist-directed propofol:

an update. Gastrointest Endosc Clin N Am. 2008;18(4):717–25.

13. Kus J, Haque S, Kazan-Tannus J, Jawahar A. Postpolypectomy

coagulation syndrome—an uncommon complication of

colonoscopy. Clin Imaging. 2021;79:133–5.

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as part of Microscopic Colitis Awareness Week

after research has shown that 87.5% of people

suffering with the condition are female - most

of whom are diagnosed between the ages of

50 and 70. [1] [2]

Microscopic colitis is a leading cause of

diarrhoea in older adults and it can have a

devastating impact on a person’s quality of life.

Scientists estimate that around 67,200 people

are living with microscopic colitis in the UK.

[3] [4]

Patients often find it difficult to manage

jobs, socialise, travel and take part in family

life because of the urgent nature of their

symptoms and their need to be near to toilet

facilities at all times. Coping with this often

leaves sufferers feeling very isolated and can

have a significant and detrimental effect on

their mental wellbeing.

Many people suffer for years with microscopic

colitis but the correct diagnosis and treatment

can make a huge and dramatic difference to a

person’s quality of life.

Julie, aged 42 from Sidcup in Kent, was

diagnosed with microscopic colitis in 2020.

Julie said:

“The symptoms of microscopic colitis are

awful. I experienced crippling stomach pain,

nausea as well as watery diarrhoea which

lasted for several weeks and only stopped

when I was diagnosed and began a treatment

of steroids. It all had a massive impact on

mental health since this was during lockdown

and I worried about what could be wrong.

“It’s a very isolating condition and I can

understand why it’s called a hidden disability.

It’s been over a year since I was diagnosed

and I’m still having flare-ups. I am constantly

thinking about what I am eating and when I

am out where the nearest facilities are - it’s


At least 1 in 1,000 people are thought to have

microscopic colitis in the UK with 17,000 new

cases being diagnosed each year, but the real

number could be a lot higher because it’s often

underreported and misdiagnosed.[5] [6] One

study showed that one in three patients

with microscopic colitis were initially

incorrectly diagnosed with Irritable Bowel

Syndrome. [7] It is also a growing disease and

the number of patients diagnosed has been

increasing over the past 20 years. [8]

Microscopic colitis is named because, unlike

other inflammatory bowel diseases (IBD), like

Crohn’s disease or ulcerative colitis, it can’t

be diagnosed with a colonoscopy alone and a

sample of tissue taken from the bowel must be

examined under a microscope to identify the

condition. However, once confirmed, treatment

with prescribed medicine (a steroid called

budesonide) is available and has shown to be

very effective and often life-changing. [9]

The causes of microscopic colitis and the

reason it affects women disproportionately

are still unclear. As it is a relatively new

disease (first described in 1976) it has led


Gastroenterology Today welcomes the submission of

clinical papers and case reports or news that

you feel will be of interest to your colleagues.

Material submitted will be seen by those working within all

UK gastroenterology departments and endoscopy units.

All submissions should be forwarded to info@mediapublishingcompany.com

If you have any queries please contact the publisher Terry Gardner via:





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to a presumption that it is environmental

as opposed to genetic factors that are

responsible for its occurrence. [10]

have to, so my main message this Microscopic

Colitis Awareness Week is don’t suffer in

silence and seek help from your GP if you’re

experiencing symptoms.”

[10] https://www.ncbi.nlm.nih.gov/pmc/


[11] Lansoprazole and omeprazole are the

most commonly known.

Prior studies have suggested that a range of

medications including proton pump inhibitors

(PPIs) - which are used to reduce stomach

acid [11], nonsteroidal anti-inflammatory drugs

such as ibuprofen, statins, antidepressants,

aspirin, and beta blockers may be associated

with the disease as well as cigarette smoking

and a co-diagnosis of an auto-immune

disease. [12] [13]

What is clear is that women are at substantially

higher risk of having microscopic colitis

than men. [14] Despite this marked gender

discrepancy, the literature on reproductive

and hormonal factors is very limited. Some

scientists have hypothesised that there is a

link with microscopic colitis and the use of

oral contraceptive pills and HRT [15] but more

research is needed for this to be conclusive.

Julie Harrington, CEO of Guts UK, said:

“Thousands of people across the country are

quite literally housebound with symptoms of

microscopic colitis and we now know that

the rates are increasing and are likely to grow

further as the population ages.

“Further research is desperately needed to

identify risk factors and find out why women

are far more likely to suffer from microscopic

colitis so we can move to a place where

prevention and faster diagnosis is possible.

“In the meantime, I hope that this year’s

Microscopic Colitis Awareness Week will raise

awareness of this extremely difficult condition

and that sufferers discover the simple

treatments that can make a huge and dramatic

difference to their quality of life.”

Professor Shaji Sebastian, Consultant

Gastroenterologist at Hull University Teaching

Hospitals NHS Trust and Guts UK trustee added:

“Scientists still don’t fully understand what

causes microscopic colitis and further research

is clearly needed to determine what could be a

combination of factors.

“What we do know is that the condition can

be very debilitating but with the right tests it’s

also very treatable. Early diagnosis is crucial to

prevent patients from suffering when they don’t

Julie from Sidcup added:

“There is very little awareness of microscopic

colitis, but I am sure there are many people

suffering with it without knowing. My

message for anyone with symptoms is that

if you feel that things aren’t quite right and

you’re struggling to get a diagnosis then

persevere and push for an appointment with

a gastroenterologist. The treatments available

can certainly improve symptoms.”

Anyone experiencing symptoms is advised

to see their GP, contact Guts UK for more

information or visit gutscharity.org.uk


[1] 7:1 female to male meaning 87.5%

of people with the condition are

women and women are 700x more

likely to have the condition than men:



hxYBP - Other studies have said it may

be as high as 9:1.

[2] https://gutscharity.org.uk/advice-andinformation/conditions/microscopiccolitis-2/

[3] https://www.ncbi.nlm.nih.gov/pmc/


[4] Aprox. 67,222 people are living with

Microscopic Colitis in the UK - around

59,000 women and 8,000 men.

[5] https://www.crohnsandcolitis.org.uk/



[6] Tong J et al. Am J Gastroenterol 2015;

110(2): 265-76. Office for National

Statistics. Statistical Bulletin: 26 June



[7] Limsui D et al. Inflamm Bowel Dis 2007:

13(2): 175-81 https://www.ncbi.nlm.nih.


[8] Münch A, Aust D, Bohr J, Bonderup O,

Fernández Bañares F, Hjortswang H, et

al. Microscopic colitis: current status,

present and future challenges: statements

of the European Microscopic Colitis

Group. J Crohns Colitis (2012) 6(9):932–

45. doi:10.1016/j.crohns.2012.05.014

PubMed Abstract | CrossRef Full Text |

Google Scholar

[9] https://gutscharity.org.uk/advice-andinformation/conditions/microscopiccolitis-2/

[12] https://www.ncbi.nlm.nih.gov/pmc/


[13] https://www.crohnsandcolitis.org.uk/



[14] Weimers P, Ankersen DV, Lophaven S,

Bonderup OK, Münch A, Løkkegaard

ECL, Burisch J, Munkholm P. Incidence

and prevalence of microscopic colitis

between 2001 and 2016: A Danish

nationwide cohort study. J Crohns Colitis.

2020 [PubMed] [Google Scholar]

[15] https://www.ncbi.nlm.nih.gov/pmc/


Health care professionals

urged to ‘think EOE’ for

patients suffering from

dysphagia or food bolus


An easily treatable, upper GI condition

which causes dysphagia and food bolus

obstruction, is going undiagnosed,

sometimes for years, 1 leaving thousands of

sufferers needlessly living with significant

discomfort, anxiety and embarrassment.

Additionally, Eosinophilic Oesophagitis

(EoE) is known to be the most common

single reason for attendance at A&E for

food bolus obstruction removal. 2 Yet

despite this, EoE - which is believed to

affect around 23,500 people in the UK 2 –

takes on average up to eight years to be

diagnosed. 3

Now the UK charity EOS Network is running

a clinical and public awareness campaign

urging both the general public and healthcare

professionals, in particular A & E doctors and

nurses, GPs and practice nurses, to ‘Think

EoE’. During the Awareness Week, volunteers

will be visiting GP surgeries with patient leaflets

and posters whilst the EOS Network clinical

community are being encouraged to put up

‘Think EoE’ posters in their staffrooms.

Eosinophilic Oesophagitis (EoE) is an immunemediated

disease, most probably caused by

food allergies or other environmental ‘triggers’

which occurs in the upper gut or oesophagus.


This results in inflammation of the mucosa in




the oesophagus which, if left untreated, can

lead to oesophageal remodelling including the

formation of furrows leading to strictures. In turn

this creates the difficulties with swallowing food.

Sufferers of Eosinophilic Oesophagitis (EoE) will

typically have a history of ‘slow eating,’ drinking

lots of water whilst eating and avoiding tough,

chewy or starchy foodstuff such as meat, rice

and bread. They are often labelled ‘fussy eaters’

and may avoid social eating occasions for fear

of choking, coughing or retching in public.

EoE was identified as a disease in the 1990s,

yet many primary care physicians are still

unaware of the condition, often mistaking it

for GORD (gastro-oesophageal reflux disease)

or dyspepsia, 4 whilst patients admitted to

A&E with food bolus obstruction will typically

be referred back to their GP rather than to a


An EoE diagnosis requires 6 biopsies taken

from at least 2 sites in the oesophagus to

specifically count the number of eosinophils

present. Yet whilst diagnosis is relatively

straightforward, lack of clinical awareness

means that opportunities are often missed,

and the patient can spend years going

between GP and hospital in a search for the

cause of their discomfort. Some patients have

even been told that the condition is caused by

psychological issues.

‘Whether it is at primary care level, at A&E

or even during referral to a gastroenterology

department, far too many of our members

are reporting years of missed opportunities

for diagnosis at every step of their disease

journey,’ explains Amanda Cordell, CEO of the

EOS Network.

‘Therefore, it is extremely important that we

improve the awareness of this condition

amongst not just the public, but healthcare

professionals too.’

‘EoE has a considerable impact on the quality

of life and the self-esteem of patients,’ explains

Professor Stephen Attwood, Consultant

Surgeon and Honorary Professor at Durham

University, and one of the first doctors to

identify and highlight the condition. ‘Not only

do many develop adaptive eating strategies

such as prolonged chewing, drinking copious

amounts of liquids and avoiding certain foods,

they also dread social situations and even

eating with the families. Adults can be labelled

as having psychological eating disorders whilst

young children often fail to thrive and can suffer

from malnutrition.

‘Therefore, it is vital that there is greater

general and clinical awareness of the

condition. A key message for clinicians

has to be that any patient who presents

with pain on eating or feeling that food is

sticking in the throat – especially if they

have a history of allergic illnesses such as

rhinitis asthma and eczema – should be

referred for biopsies with a specific request

to look for eosinophils. On diagnosis the

gastroenterologist and patient should

discuss the treatment options. These may

include dietary exclusions - although these

can often be difficult to maintain - PPIs

that are effective for some patients or a

topical steroid delivered directly to the site

of inflammation that has been shown to

maintain clinical and pathologic remission

for 48 weeks in many patients. All patients

need follow up and a long term care plan to

manage this chronic disease.’

Amanda Cordell comments ‘Our aim is to

ensure that patients are empowered with

information to take to their clinicians and that

clinicians in all specialities are aware of EoE

so that they recognise the symptoms reported

by their patients, Think EoE and provide the

appropriate care. This will be further supported

by the first British medical diagnosis and

treatment guidelines which we expect to see

published later this year.

‘EoE is a very unpleasant and life-changing

condition, but conversely it is relatively easy to

recognise, diagnose and treat,’ ‘We hope our

campaign will remind everyone to ‘Think EoE’

and help to make this happen.’



Gastroenterology Today welcomes the submission of

clinical papers and case reports or news that

you feel will be of interest to your colleagues.

Material submitted will be seen by those working within all

UK gastroenterology departments and endoscopy units.

All submissions should be forwarded to info@mediapublishingcompany.com

If you have any queries please contact the publisher Terry Gardner via:




Eosinophilic Awareness Week 16 – 22nd May

launched the ‘Think EoE’ campaign. EOS

Network activities include the development

of a patient information pack including a food

obstruction patient action plan and symptom

tracker, and emergency care education

through an A&E awareness poster. Additionally,

members of the EoE community will be visiting

local GPs to provide information leaflets and

posters to help with wider understanding of the

disease and recognition of the symptoms.

Find out more at www.eosnetwork.org

For EoE case studies, or to interview Amanda

Cordell, please contact Isla Whitcroft at Healthy

PR on 07768661189 or email Islawhitcroft@


About the EOS Network Charity

The EOS Network’s mission is to ensure

that every person with an Eosinophilic

Gastrointestinal Disease receives a prompt

accurate diagnosis, the right treatment for

them and support to live with their condition.

Its vision is for a world where everyone with an

Eosinophilic Gastrointestinal Disease can eat

without pain.

The EOS Network provides information and

support for patients and their families, a

global platform for clinicians and researchers,

educational resources and events and works

with medical bodies, manufacturers and

funders to ensure that the patient’s voice is


Brief notes on EOE (for more detail see

media pack)

EoE is clinically characterized by oesophageal

dysfunction and histologically characterized by

an eosinophil-rich inflammation, most probably

caused by common food allergies or other

environmental triggers. Often misdiagnosed as

GORD, 4 adult symptoms include dysphagia,

bolus obstruction and chest pain related

to swallowing, heartburn and regurgitation.

In children they can include reflux-related

symptoms, nausea, vomiting, abdominal pain,

refusal to eat or failure to grow. 2 Untreated

EoE can lead to oesophageal remodelling

including the formation of strictures. EoE

is the cause of more than 50% of all

emergency presentations for oesophageal

food bolus impactions. 1

Annual incidence rates of EoE in western

countries are 7 cases per 100,000 with

prevalence rates of 34 per 100,000. 2 However

for patients with dysphagia and bolus

50%. 5 Many patients have a history of atopy,

particularly asthma, allergic rhinitis and eczema. 6

EoE only received classification in the 1990s

and disease awareness, amongst both

clinicians and the general public, is thought to

be low. Currently, average time to diagnosis

is up to 8.1 years. 2 Due to the patchy nature

of the disease, diagnosis requires six biopsies

to be taken from around the oesophagus via

endoscopy. Diagnosis is defined by histological

presence of eosinophils ≥15hpf.

Treatment for EoE is focused around three

areas: dietary exclusion, drugs and dilatation.

Dietary exclusion is generally considered

hard to maintain and costly. Dilatation,

carried out when the disease has progressed

to oesophageal strictures, is an invasive

procedure which manages the symptoms

but not the cause of EoE and often has to be


Until recently, all drug treatments were off-label

and topical steroid therapy was not optimised

for delivery to the oesophagus. However

after approval from the EMA, NICE and the

SMC have now recommended budesonide

orodispersible tablet (Jorveza ® ) for active EoE

in adults, a treatment option designed to reach

the area of inflammation in the oesophagus

Current clinical guidelines can be found @

obstruction, prevalence can be between 23-



1. Gastrointest Pharmacol Ther 2016; 7(2):

207-13. Ahmed M. World J

2. Orodispersible budesonide tablets for the

treatment of eosinophilic esophagitis: a

review of the latest evidence. Ther Adv

Gastroenterol 2020, Vol. 13: 1–15. Miehlke

S, Lucendo AJ, Straumann A, Bredenoord

AJ and Attwood S

3. Gastrointest Pharmacol Ther 2016; 7(2):

207-13. Ahmed M. World J

4. Eosinophilic esophagitis N Engl J Med.

2015;373(17):1640–8. Furuta GT, Katzka


5. Prevalence of eosinophilic oesophagitis in

adults presenting with oesophageal food

bolus obstruction. World J Gastrointest

Pharmacol Ther 2015;6:244–247. Heerasing

N, Lee SY, Alexander S, et al

6. Aliment Pharmacol Ther 2016; 43(1): 3-15.

Arias Á et al

Amanda Cordell Interview

As awareness of the upper GI condition

Eosinophilic Oesophagitis grows, including

its significant impact on the quality of life

for those affected, we talk to Amanda

Cordell, Chair and Founder of the charity

The EOS Network, to discover the inspiring

story behind the founding of the charity

which supports both patients and clinicians

working in this field.

When Amanda Cordell’s seven month old baby

Samuel was diagnosed with multiple protein

allergies and eosinophilic gastrointestinal

disease back in 2003, she naturally searched

around for any information which would help

her to support her son.

‘It quickly became clear that there was absolutely

nothing out there,’ says Amanda. ‘My husband

and I felt completely helpless and very isolated.’

Today, Amanda is chair of the The EOS

Network, which grew out of a Yahoo support

group that she formed in 2005. The Network

has a strong community of parents, carers

and adult patients and over 2,000 followers on

social media. The Network provides them with

somewhere to turn for support, advice and gold

standard information on eosinophilic diseases

which run throughout the gut. Eosinophilic

Oesophagitis (EoE) is the most common

disorder, and a significant cause of oesophageal

dysphagia and food bolus, whilst Eosinophilic

Gastroenteritis (EGE), Gastritis (EG), and Colitis

(EC), all appear in the middle and lower gut.

In addition, over 100 clinical professionals from

13 countries have already signed up to the

charity’s Professional Network, all benefitting

from rapid access to the latest clinical

research, guidelines, medical education,

patient resources as well as global networking

and discussion opportunities. There are also

collaborative partnerships with medical bodies

‘Our professional network provides a platform

to connect, collaborate and innovate in all

things Eosinophilic,’ says Amanda. ‘In addition,

the ripple effect means that our members can

educate their colleagues about the condition

which is, of course vital, if more patients are to

be helped.

‘As a patient advocate and as the parent of

two children living with eosinophilic diseases,




I understand that it can feel like a pretty

hopeless situation. Having an HCP in your

corner who is supportive and knowledgeable

makes such a huge difference.”

When Amanda Cordell’s son Samuel was born

17 years ago, he slept peacefully through the

first night of his life. It was the last time he was

to enjoy that simple luxury.

‘The signs that something was wrong with

Samuel were there from the first few days of

his life, says Amanda. ‘He always seemed

uncomfortable and never settled at night.

He was a fussy eater who vomited up my

breast milk, he developed cradle cap and then

eczema which become infected so badly that

he had to be admitted to our local hospital.’

In hospital Samuel caught Rotavirus and was

placed on a special feed but even when he

was well enough to be discharged, he still

suffered constant vomiting, whilst his explosive

bowel movements overflowed his nappy.

‘We hardly slept for months,’ remembers

Amanda. ‘We would take it in turns to walk

up and down with him all night whilst he cried

or was sick. We were new parents, so it was

sometimes hard to know what was normal

and our GP and the local hospital seemed to

have little idea on how to help us. David and

I were convinced however, that there was a

connection between his bowel issues, eczema

and vomiting.’

where people understood what you were going

through but also where there was hope for the

future. I came back to the UK and started up

an online UK support group and things just

went from there.’

‘We quickly discovered that there was a

whole raft of people, often with very poorly

children who were simply desperate for help.

On the clinical side there was clearly a huge

knowledge gap and a lack of consensus on

how to treat these patients.

Their daughter Heather born in 2007 was also to

develop gut problems, eczema and immediate

allergies. “It was devasting to hear our daughter

also be given an eosinophilic diagnosis.”

We spent the next few years raising funds and

with the support of other families affected by

eosinophilic diseases in 2010, we registered

our group as a charity.

‘Sadly, in December 2013, Samuel became

seriously ill and I was forced to a back seat for

a few years, but in the meantime the need for

research, diagnosis consensus and treatments

became even greater.”

‘I went back to Cincinnati for the 2017 CURED

conference and was completely humbled

by the great work that the researchers

and patient advocates had done in driving

forward awareness and change in the USA.

The meeting had attendees and presenters

from around the globe, including the UK’s

Professor Stephen Attwood who first identified

eosinophilic oesophagitis. I came back inspired

with the aim of bringing together the global

expertise to improve disease awareness,

access to medical care and patient support for

all those suffering with eosinophilic diseases.’

The charity was relaunched in 2019 as

the EOS Network, now supported by a

medical and scientific board. The change

in constitution provided two arms, one a

community hub for patients and their families

and the other a global network for HCPs.

‘There is a real need to expand our reach,

to more patients their families and HCPs, ‘

says Amanda. ‘Both here and abroad it is still

difficult for people to get in front of an HCP who

understands EOS diseases which can mean a

delay in diagnosis and access treatments. The

last 8 months have been a huge success but

there is still a lot of work to be done.”

If you need more information or you would like

to get involved go to www.eosnetwork.org or

email contactus@eosnetwork.org

At seven months, Samuel was referred to a

paediatric gastroenterologist who diagnosed

him with eosinophilic gastrointestinal disease

as the cause of his relentless symptoms.


‘We didn’t know it then, but we were at the start

of a very long, tough journey,’ says Amanda.

Samuel was placed on a highly restrictive

diet with elemental feed and Amanda started

to search for information that might help her

and David to support their son. Whilst there

was virtually no information on the condition

in the UK and Europe, Amanda learned about

the work being carried out into gut allergies

and eosinophilic disorders at the Cincinnati

Children’s Hospital. In 2005 she and her

husband David attended a conference when,

for the first time, they realised the value of

having a support group.

‘It was such as relief to be in an environment



Building a world where

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At Cyted we exist to tackle

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Cytosponge diagnostic tool is

transforming cancer detection.

By enabling clinicians to make

decisions quicker and with

more confidence, they are

detecting disease earlier

and saving lives faster.

The Cytosponge is a patient-friendly

early detection test for oesophageal

cancer in people living with heartburn

or reflux symptoms. This test is a

‘sponge-on-a-string’ device, coupled

with next generation biomarkers, to

collect cells from the oesophagus, which

are then sent to the Cyted laboratory

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our digital platform. Pathologists are then

guided to the location that needs their

attention in seconds to identify the

patients who are most at risk of Barrett’s

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Close to 1% of the global population

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Traditionally, it is diagnosed by

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May, 2022 – Opioids are widely used to treat serious pain,

including in patients with cancer. The majority of these

patients will experience the side-effect of opioid-induced

constipation (OIC), caused by the opioids binding to the

μ-receptors in the enteric system.

aware of the importance of diagnosing OIC, monitoring the condition

and providing appropriate treatment. For example, peripheral-acting mu

opioid receptor antagonists (PAMORAs) are a unique class of drugs that

act directly on the mechanism causing OIC, and are therefore far more

effective than traditional treatments.

There has been a sharp increase in the prescribing of opioids to patients

with chronic pain. However, despite the debilitating side effect of

constipation many healthcare professionals continue to prescribe opioids.


The Cost of Opioid-induced Constipation report recommends that




OIC has a devastating effect on people’s lives but is often treated with

laxatives, which have limited effect. OIC frequently has a negative impact

on patients’ quality of life, including their ability to perform daily activities

and work productively, yet there is little recognition of the condition and

how to manage it.

The Bowel Interest Group’s latest report, The Cost of Opioid-induced

Constipation, will be published in June and sets out to educate primary

and secondary healthcare professionals in the management of OIC.

Key facts

• Studies suggest that OIC affects between 41% and 57% of patients

taking opioids for pain and 87% of patients with terminal cancer using

opioids. 1

• Doctors are prescribing laxatives for OIC, even though their

effectiveness is limited.

• Constipation is one of the most common reasons patients avoid

taking opioid treatments or stop taking them.

• There appears to be a clear relationship between higher levels of

opioid analgesic prescribing and laxative prescribing rates. 2

• There is a close correlation between opioid prescribing rates and

admissions to hospital for constipation. 3

• In 2018-19, the estimated annual spend by NHS England on

constipation was £168 million. 4

• In 2021, nearly 23 million opioid analgesic prescriptions were

dispensed in the community, at a cost of approximately £202 million. 2

OIC is underdiagnosed and therefore undertreated 1 or sometimes

inappropriately treated. Not all doctors adhere to the Rome IV criteria

for diagnosing OIC. Conventional treatments such as dietary changes

and laxatives are rarely effective in treating OIC, but doctors continue to

prescribe them.

OIC can be very psychologically distressing for patients, who may

choose to manage the condition themselves. This can include reducing

their dose of opioids or even stopping taking opioids altogether.

Better education of health professionals is needed so that they are


1. Cobo Dols M., Beato Zambrano C., Cabezón-Gutiérrez L., et al. (2021). One-year efficacy and safety of naloxegol

on symptoms and quality of life related to opioid-induced constipation in patients with cancer: KYONAL study.

BMJ Supportive & Palliative Care.

2. Prescription data for section code 040702 (Opioid Analgesic Prescribing), 0106 Laxative Prescribing), and

010606 (PAMORA Prescribing) from Jan 2017 – Dec 2021. Accessed March 2022 from NHS BSA England

Prescribing Database and Openprescribing.net.

• take a more proactive approach in the management of OIC, using a

standard, symptom-based definition of the condition

• educate themselves about treatment options

• ask the patient regularly about symptoms

• ensure that patients receive therapy that manages their pain

appropriately while avoiding the debilitating consequences of OIC.

Professor Anton Emmanuel, Professor in Neuro-Gastroenterology

at University College London and Consultant Gastroenterologist at

University College Hospital and the National Hospital for Neurology and

Neurosurgery (Queen Square), says:

“The Cost of Opioid-Induced Constipation Report emphasises the

devastating impact that OIC has on patients, who face a stark choice of

whether to endure the impact of chronic pain, or the pain of the constipation

that results from taking the very painkillers that should be helping them.

Patients' quality of life is severely impacted by the condition – what they are

experiencing is often very distressing, not just a ‘nuisance’. Studies suggest

that OIC affects between 41% and 57% of patients taking opioids for pain,

and up to 87% of patients with terminal cancer using opioids.

“OIC is often misdiagnosed and therefore sometimes inappropriately

treated. Usual constipation treatments such as diet changes of

prescribing of laxatives rarely work in treating OIC, because they do

not target the underlying cause; the opioid binding to the μ-receptors.

Inappropriate treatment leaves many patients to attempt to treat the

condition themselves, while all the time enduring their chronic pain.

More education for healthcare professionals in diagnosing, appropriately

treating and managing OIC is needed. The Cost of Opioid-Induced

Constipation Report highlights the urgency of the need and also the

cost, both in terms of the financial cost to the NHS, and the cost of the

impact on patients’ wellbeing and quality of life.”

The full report will be available on the Bowel Interest Group’s website in


For more information on the work of the Bowel Interest Group, visit


3. Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020. Accessed May

2020 from Vantage System provided by Health IQ.

4. Bowel Interest Group (2020). Cost of constipation report. 2020. Available from: https://bowelinterestgroup.co.uk/


5. Kumar, L., Barker, C., Emmanuel, A. (2014). Opioid-Induced Constipation: Pathophysiology, Clinical

Consequences, and Management, Gastroenterology Research and Practice. 2014. https://doi.






A clinical validation study conducted at Oulu University

Hospital (OUH) has confirmed the high accuracy of BIOHIT

Oyj’s new generation GastroPanel ® test for the diagnosis of

atrophic gastritis (AG) and Helicobacter pylori (Hp) infection

in patients referred for gastroscopy. 1 This unique blood test is

designed for the first-line diagnosis of Hp infection and AG in

patients with upper abdominal symptoms, such as dyspepsia

and gastro-oesophageal reflux disease (GORD), before

endoscopy. GastroPanel is also the only test on the market

capable of monitoring the regulatory mechanism of acid

output in the stomach.

Hp infection, AG and high acid output are important risk factors

for gastric and oesophageal cancers. The new generation (unified)

GastroPanel test works on the same principle as the original

GastroPanel ELISA test and is designed to harmonize the ELISA

processing conditions of four biomarkers. This highly informative assay

is therefore a cost-effective solution for population-based screening for

the risk of gastric cancer in asymptomatic and symptomatic individuals,

and its efficacy has already been confirmed by several studies in both

high- and low-risk countries.

This latest study evaluated the diagnostic accuracy of the new

generation GastroPanel test for the diagnosis of both AG and Hp

infection in patients referred for gastroscopy from Primary Care with

different indications. Along with the previously published clinical

validation studies, 2,3 this biopsy-confirmed study was designed to

verify the diagnostic capabilities of the new generation GastroPanel

test compared to the current gold standard (gastroscopy and biopsy

analysis), and to demonstrate its performance was comparable to the

original GastroPanel test. The positive results from this study also pave

the way for BIOHIT’s new GastroPanel Quick Test (point of care test)

which will be launched in Q1 2022.

Dr. Olli-Pekka Koivurova, Principal Investigator of the study at OUH,

commented: “A total of 522 patients referred for gastroscopy at the

Gastro Centre, OUH, were consented and enrolled for this particular

study. Blood was sampled for all patients using the GastroPanel test,

along with performing quality-controlled gastroscopies with mucosal

biopsies. The results confirmed that the new generation GastroPanel

is a highly accurate test for the non-invasive diagnosis of AG and Hp

infection in patients referred for diagnostic gastroscopies.”

For more information visit www.biohithealthcare.co.uk/gastropanel.

1. Koivurova O-P, et al. Serological biomarker panel in diagnosis of

atrophic gastritis and Helicobacter pylori infection in gastroscopy

referral patients. Clinical validation of the new generation GastroPanel ®

test. Anticancer Res. 2021, 41, 5527-5537.

2. Koivurova O-P, et al. Screening of the patients with autoimmune

thyroid disease (AITD) and type 1 diabetes mellitus (DM1) for atrophic

gastritis (AG) by serological biomarker testing (GastroPanel ® ). EC

Gastroenterol. Digest. Syst, 2020, 7, 181-195.

3. Mäki M, et al. Helicobacter pylori (Hp) IgG ELISA of the newgeneration

GastroPanel ® is highly accurate in diagnosis of Hp-

Infection in gastroscopy referral patients. Anticancer Res, 2020, 40,


About BIOHIT Healthcare Ltd

BIOHIT Healthcare Ltd (www.biohithealthcare.co.uk) is part of

the Finnish public company, BIOHIT OYJ, which specialises in the

development, manufacture and marketing of products and analysis

systems for the early diagnosis and prevention of gastrointestinal

diseases. The company’s many unique and patented diagnostic tests

transform clinical practice and make screening, diagnosis and monitoring

of gastrointestinal diseases efficient and cost effective. Non-invasive

diagnostics are at the core of BIOHIT’s offering, making it the provider of

choice for leading gastroenterologists and laboratory scientists worldwide.





Symprove is a patented water-based probiotic that delivers viable

bacteria to the gastrointestinal tract, as evidenced by extensive

in-vitro data utilising the Simulator of the Human Intestinal

Microbial Ecosystem (SHIME ® ). 1-3 Independent research to date

has been undertaken in collaboration with research partners

including University College London and King’s College London.

With existing randomised controlled trials including irritable

bowel syndrome, inflammatory bowel disease and diverticular

disease completed, 4-6 further studies underway with key

research partners including Sheffield Hallam University, include

diverticulitis and Parkinson’s disease. These studies are due for

publication in 2022-2023. A full summary of Symprove published

data is available at symproveforprofessionals.com.

Dr Andrew Thillainayagam, consultant gastroenterologist, Imperial College

Healthcare NHS Trust, London: “Behavioural disorders of the gut, what we

call functional bowel disorders, of which IBS is one, have a terrible impact on

people’s quality of life. I recommend Symprove to almost all of my patients

who have functional problems in the gut, based on the enormous amount of

clinical evidence behind it, which includes randomised controlled trials.”

London: “Symprove is different

from other probiotics because

it is water-based, which means

it limits exposure to gastric

juices and digestive enzymes in

the stomach. Symprove is also

fermented, enabling the bacteria

to grow and become used to

an acidic environment as part of

the manufacturing process. This

means when a patient swallows

Symprove, the bacteria are able to

survive the stomach acid and then

thrive in the colon.”

Barry Smith, Founder of Symprove Ltd, says: “At Symprove, we pride

ourselves on our loyal customer base, with 92% of people feeling the

difference at 12 weeks in their Symprove journey. We are hugely excited

about what the future holds, as we expand our research programme to

support different patient groups.”

Prof Simon Gaisford, Professor of Pharmaceutics, University College

Find out more at symproveforprofessionals.com


1. Fredua-Agymean M, et al. Benef Microbes 2015;6(1):141–51.

2. Ghyselinck J, et al. Int J Pharm X 2021:3:100087.

3. Ghyselinck J, et al. Int J Pharm 2020;587:119648.

4. Sisson G, et al. Aliment Pharmacol Ther 2014;40(1):51–62.

5. Bjarnason I, et al. Inflammopharmacology 2019;27(3):465–473.

6. Kvasnovsky CL, et al. Inflammopharmcology 2017; doi: 10.1007/s10787-017-0363-y.





The BIOFIRE ® Blood Culture Identification 2 (BCID2) Panel

rapidly detects pathogens and antimicrobial resistance genes,

directly from positive blood cultures, to shorten the time to

optimal therapy for sepsis. To monitor accuracy and precision

of the whole system the new Streck MDx-Chex Control is

the first-of-its-kind quality control, specifically designed to

meet the standards for verifying the entire analytical process

of the BioFire BCID2 sepsis assay. It provides confidence

in instrument results to ensure the best patient treatment


Now available in the UK from Alpha Laboratories, MDx-Chex

evaluates the entire analytical process of the assay, including cell

lysis, DNA extraction, purification and removal of PCR inhibitors, as

well as qPCR amplification, detection and analysis.

MDx-Chex contains 43 bacteria, yeasts and antimicrobial resistance

gene targets covering all those tested on the BIOFIRE BCID2 Panel. The

intact, inactivated microorganisms are suspended in a matrix of stabilized

red and white blood cells, plus blood culture media components, designed

to challenge the lysis and purification processes, just like a patient sample.

Routine use of MDx-Chex for BCID2 as a full process quality control can help

identify variations in the test system that can lead to incorrect results. It can be

used as a 3rd party quality control to support ISO 15189 compliance.

View the MDx-Chex for BCID2 Best Practice Guide at:


Please visit www.alphalabs.co.uk for further information or contact

Alpha Laboratories on 0800 38 77 32 or email




Thousands of

healthcare professionals

recommend Symprove

Symprove is a live liquid-based probiotic

containing four strains of bacteria*

Evidence-based: Independent research conducted at

University College London and King’s College London.

Safety: Well tolerated, long history of safe use.

All strains are fully characterised.

Here are the reasons why:

Survival: In vitro/in vivo research demonstrating

viability of bacteria through the gut.

Formulation: Manufactured to ensure

bacterial tolerance through the gut.

For more information please visit: symproveforprofessionals.com


*Lacticaseibacillus rhamnosus NCIMB 30174, Enterococcus faecium NCIMB 30176, Lactobacillus acidophilus NCIMB 30175, Lactiplantibacillus plantarum NCIMB 30173.


Helicobacter Test INFAI ®

The most used 13 C-urea breath test for the

diagnosis of Hp-infection worldwide

• more than 4.5 million INFAI tests performed in Europe

• approved for children from the ages of 3 to 11

• special INFAI test for patients with dyspepsia taking PPIs

• cost-effective CliniPac Basic version for hospital use

INFAI Institute for Biomedical Analysis & NMR Imaging, INFAI UK Ltd

Innovation Centre, University Science Park, University Road, Heslington, YORK YO10 5DG, UK

Phone +44 1904 435 228 - Fax +44 1904 435 229 - mail: info@infai.co.uk - Visit us at www.infai.com

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